Around 10% of people will have peptic ulcer disease (PUD) at some point in their life. The majority of peptic ulcers are caused by bacteria called Helicobacter pylori (H. pylori) or by taking ASA (acetylsalicylic acid) or nonsteroidal anti-inflammatory drugs (NSAIDs; e.g., ibuprofen*, ketoprofen, naproxen).
- Gastric ulcers are sores in the lining of the stomach.
- Duodenal ulcers are those in the first part of the small intestine, called the duodenum. This is an area where food is digested after passing through the stomach.
Causes
Although stress and spicy foods might make the symptoms of peptic ulcer worse, they aren't the cause of the condition as was once thought.
A bacterium called H. pylori causes the majority of ulcers. The bacteria can spread into the mucus lining that usually protects the stomach and small intestine from digestive acids, damaging it in the process. By 60 years of age, up to 50% of people are infected with this bacteria, but only 10% to 20% of these people will actually develop stomach problems.
The other major cause of PUD is the use of ASA (acetylsalicylic acid) and other NSAIDs such as ibuprofen or naproxen. NSAIDs can penetrate the lining of the stomach and release substances that damage cells. NSAIDs also block natural chemicals called prostaglandins that can help to protect and repair those cells. People more at risk of ulcers caused by NSAIDs include those who:
- are seniors
- have a history of a peptic ulcer
- have a family history of peptic ulcer disease
- are also taking glucocorticoids (e.g., prednisone, dexamethasone)
- are taking high doses of NSAIDs or ASA
- have several medical conditions
- are taking more than one NSAID or ASA
Excessive alcohol use can put people at higher risk for PUD, but it isn't a true cause.
Symptoms and Complications
The most common symptom of peptic ulcers (both duodenal and gastric) is a gnawing or burning pain in the abdomen between the breastbone and the navel, sometimes passed off as "heartburn." An ulcer can also feel like a dull ache or strong hunger pangs. Yet some people, especially the elderly, may not feel any pain at all from an ulcer. Ulcer pain can come or go and can be aggravated by eating or an empty stomach. Ulcers can also cause belching and bloating.
The most common complication of stomach and duodenal ulcers is bleeding. Although the blood loss is usually too slow to be noticed, it might be enough to make you tired, pale, and weak.
If bleeding from the peptic ulcer is heavier, blood may show up in the stool or vomit. Stools that have blood in them may look tarry, black, or red. If you notice any of these signs, see a doctor right away. If a bleeding ulcer is severe, it can be fatal if left untreated. Keep in mind also that, since NSAIDs are such strong painkillers, they can mask the pain of bleeding ulcers.
Very rarely, ulcers can make a hole, called a perforation, in the stomach or intestine. This can cause sudden and severe pain. Sometimes an ulcer can create a blockage out of the stomach or in the duodenum. This may cause bloating, feeling full after eating, vomiting, and weight loss.
If an ulcer causes scarring, spasm, or inflammation, it is considered a gastric outlet obstruction and may lead to weight loss and dehydration. It may cause loss of appetite with fullness after eating, or it may cause large-volume vomiting up to 6 hours after a meal.
Making the Diagnosis
If you have the typical symptoms of PUD, your doctor will perform a physical exam and may order one or more of the following tests:
A breath test (drinking a fluid and exhaling into a tube), blood test, or stool test may be used to check for H. pylori infection. If you have H. pylori, treatment may be given to cure the infection without the need for more invasive tests.
A series of GI (gastrointestinal) X-rays may be done. These are X-rays of your stomach, duodenum, and esophagus (the swallowing tube). To make the ulcer easier for the doctor to see, you'll first need to swallow a chalky liquid called barium.
Endoscopy is another test used to detect ulcers. After numbing the throat, the doctor carefully guides a thin tube with a tiny camera on its end into the mouth and down the throat to get close-up pictures of the esophagus, stomach, and duodenum.
If ulcers are detected by these tests, then appropriate treatment will be prescribed.
Finally, all people older than 50 years who, for the first time, show symptoms suggestive of a stomach acid-related disorder, and anyone of any age with "alarm" features such as vomiting, bleeding, anemia, an abdominal mass, unexplained weight loss, or trouble swallowing should have an endoscopy to identify the cause quickly and to rule out cancer.
Treatment and Prevention
Medical treatment focuses on eliminating the H. pylori bacteria in people where it has been detected. The majority of peptic ulcers caused by H. pylori can be cured with a combination of antibiotics and acid-reducing medications called proton pump inhibitors (PPIs; e.g., omeprazole, lansoprazole, esomeprazole, pantoprazole, rabeprazole) plus two antibiotics (clarithromycin plus amoxicillin or metronidazole), all taken twice a day for 2 weeks.
Other combinations of acid-reducing medications and antibiotics may also be used, including ones that use a total of four medications. For some people, several courses of treatment may be needed to get rid of H. pylori. Once the treatment for H. pylori is complete, the acid-suppressing medication should be continued for a total of 4 to 6 weeks.
When an ulcer is not associated with H. pylori or is caused by NSAIDs, treatment with a PPI is prescribed for 2 to 4 weeks. Some people may need to continue treatment for longer periods of time. Another type of acid reducer, H2-antagonists (e.g., ranitidine, nizatidine), may also be used.
If the peptic ulcer was caused by NSAIDs, such as ASA, your doctor will most often recommend that you stop taking them if possible. Some people are more susceptible to peptic ulcers caused by NSAIDs, including those who:
- are seniors
- have a history of a peptic ulcer
- are also taking glucocorticoids (e.g., prednisone, dexamethasone)
- are taking high doses of NSAIDs or ASA
- have several medical conditions
- are taking more than one NSAID or ASA
If you're taking a NSAID and have one of these risk factors, your doctor may prescribe a protective medication to take along with it. Acid-suppressing medications (e.g., PPIs) or misoprostol may be used for this. Misoprostol encourages the stomach to produce its protective mucus coating and improves blood flow.
It's important for people with PUD to quit smoking. Smoking can delay healing and can cause ulcers to return.
Very rarely, surgical treatment may be needed for PUD and its complications.
